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Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario, Canada

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What is the association of crowding in nursing homes, defined as the mean number of residents per bedroom and bathroom, with nursing home coronavirus disease 2019 (COVID-19) mortality?

Findings  In this cohort study that included more than 78 000 residents of 618 nursing homes in Ontario, Canada, COVID-19 mortality in homes with low crowding was less than half (578 of 46 028 residents [1.3%]) than that of homes with high crowding (874 of 32 579 residents [2.7%]).

Meaning  Shared bedrooms and bathrooms in nursing homes are associated with larger and deadlier COVID-19 outbreaks.

Abstract

Importance  Nursing home residents have been disproportionately affected by coronavirus disease 2019 (COVID-19). Prevention recommendations emphasize frequent testing of health care personnel and residents, but additional strategies are needed.

Objective  To develop a reproducible index of nursing home crowding and determine whether crowding was associated with COVID-19 cases and mortality in the first months of the COVID-19 epidemic.

Design, Setting, and Participants  This population-based retrospective cohort study included more than 78 000 residents across more than 600 nursing homes in Ontario, Canada, and was conducted from March 29 to May 20, 2020.

Exposures  The nursing home crowding index equaled the mean number of residents per bedroom and bathroom.

Main Outcomes and Measures  The cumulative incidence of COVID-19 cases confirmed by a validated nucleic acid amplification assay and mortality per 100 residents; the introduction of COVID-19 into a home (≥1 resident case) was a negative tracer.

Results  Of 623 homes in Ontario, we obtained complete information on 618 homes (99%) housing 78 607 residents (women, 54 160 [68.9%]; age ≥85 years, 42 919 [54.6%]). A total of 5218 residents (6.6%) developed COVID-19 infection, and 1452 (1.8%) died of COVID-19 infection as of May 20, 2020. COVID-19 infection was distributed unevenly across nursing homes; 4496 infections (86%) occurred in 63 homes (10%). The crowding index ranged across homes from 1.3 (mainly single-occupancy rooms) to 4.0 (exclusively quadruple occupancy rooms); 308 homes (50%) had a high crowding index (≥2). Incidence in high crowding index homes was 9.7% vs 4.5% in low crowding index homes (P < .001), while COVID-19 mortality was 2.7% vs 1.3%, respectively (P < .001). The likelihood of COVID-19 introduction did not differ (high = 31.3% vs low = 30.2%; P = .79). After adjustment for regional, nursing home, and resident covariates, the crowding index remained associated with an increased incidence of infection (relative risk [RR] = 1.73, 95% CI, 1.10-2.72) and mortality (RR, 1.69; 95% CI, 0.99-2.87). A propensity score analysis yielded similar conclusions for infection (RR, 2.09; 95% CI, 1.30-3.38) and mortality (RR, 1.83; 95% CI, 1.09-3.08). Simulations suggested that converting all 4-bed rooms to 2-bed rooms would have averted 998 COVID-19 cases (19.1%) and 263 deaths (18.1%).

Conclusions and Relevance  In this cohort of Canadian nursing homes, crowding was common and crowded homes were more likely to experience larger and deadlier COVID-19 outbreaks.

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Article Information

Accepted for Publication: September 18, 2020.

Published Online: November 9, 2020. doi:10.1001/jamainternmed.2020.6466

Corresponding Authors: Kevin A. Brown, PhD, Dalla Lana School of Public Health, University of Toronto, 480 University Ave, Ste 300, Toronto, ON M5G1V2, Canada (kevin.brown@utoronto.ca); and Nathan M. Stall, MD, Division of General Internal Medicine and Geriatrics, Mount Sinai Hospital, 600 University Ave, Ste 475, Toronto ON M5G 2C4 Canada (nathan.stall@sinaihealth.ca).

Author Contributions: Dr Brown had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Brown, Jones, Garber, Costa, Stall.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Brown, Jones.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Brown, Jones.

Obtained funding: Costa.

Administrative, technical, or material support: Brown, Schwartz, Garber, Costa.

Supervision: Brown, Garber, Costa.

Conflict of Interest Disclosures: Dr Stall is supported by the Department of Medicine’s Eliot Phillipson Clinician-Scientist Training Program and the Clinician Investigator Program at the University of Toronto and the Vanier Canada Graduate Scholarship. Dr Costa holds the Schlegel Chair in Clinical Epidemiology and Aging at McMaster University. Dr Brown reported a familial tie with an employee of an architecture firm that has consulted on projects for implementing physical distancing in shelter systems. No other disclosures were reported.

Additional Contributions: We acknowledge the support of Michael Hillmer, PhD, Kamil Malikov, MBA, MD, and Sping Wang, PhD, Ontario Ministry of Health Capacity Planning and Analytics Division, for assistance with data acquisition, interpretation, and analysis. No compensation was received for their contributions.

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